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Mission: "To assist our clients in developing the best possible
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Aviation Human Factors Industry News

The following weekly issues have been generously
provided by Roger Hughes, President, Decoding Human Factors, Inc.

They are excellent articles and deal with the all
important subject of human factors. Please have a read and let others know
of this site.

Check back weekly for the latest news and thanks
Roger for sharing this information. Please share it with your fellow
workers so we all can be just a bit Safer by learning from others mistakes.

Reading these can help maintain our awareness of
Human Factors and remind us that "If we are Human - We also could make the
error."

This is into its 11th year (2015) so there is a
lot to be learned here.

Thank you Roger for your 11 years of hard work and dedication to the Aviation
Human Factors Newsletter! We look forward to reading all the future
editions in 2015. - Renée Dupont-Adam

Volume
11, Issue
1 - Flying got much safer in 2013 (However, we can still get even Safer) DA: Man's death on Logan tarmac was an accident (Human Error) Don’t Bother Me with the Facts! - FAA Safety Team (Worth a Read) and much more.

2014

Volume
10, Issue
26 - Human Factors training is just common sense... Or is
it? (Written by our own Mr. Gordon Dupont!) Most plane accidents happen while still at airports(WHAT?) Complacency Revisited (Let's look at the Management and Complacency) and much more.

Volume
10, Issue
24 - Cargo Pilots Say Fatigue Leading To Big
Danger Below (Cargo pilots doen't have the same fatigue rules as passanger pilots - why?) Man Pleads Guilty To Fraud Over Helicopter Weights(Is this reckless behaviour? You decide!) Take the Fight to the Enemy: Combating Human Error
is Still Our Top Challenge (Tony Kern - well worth the read) and much more.

Volume
10, Issue
22 - Safety is the heartbeat of the aviation industry:
Lufthansa (And so it should be!) Russia Air Safety Record Near Bottom of Global
League(Why? Weak Regulations or?) NTSB: Pilot Error Caused Fatal Jet Crash (Fatigue was only one of the many factors) and much more.

Volume
10, Issue
18 - Lion Air crew castigated in Bali crash final report (Lack of Awareness and many other factors) DGCA, SpiceJet turned blind eye to repeated lapses
by senior pilot(Was it a norm?) Flying Under the Influence of Fatigue (Excellent Article on Fatigue) and much more.

Volume
10, Issue
16 - FAA Proposes $110,000 Civil Penalty Against Air Evac
EMS (What do you think?) Factors That Led To Risk Of Collision For An Aircraft
Landing At Toronto's Lester B. Pearson Airport In
March 2013(What were the Human Factors that led to this?) Boeing Forecasts Rising Demand for Commercial
Pilots and Technicians (Get into Aviation!) and much more.

Volume
10, Issue
15 - First aviation mechanic display added to the National
Museum of the U.S. Air Force (I think this is awesome!) Namibia: Taking Photos Caused Plane Crash(Distraction) Most Common Major Stressful Event? Health. And
That Impacts Sleep (Fatigue!) and much more.

Volume
10, Issue
14 - The Aggravators (too much
stress, pressure and / or fatigue) NTSB: Plane's Controls Reversed in Deadly Merrill
Field Crash(What happened with the machanic for him to do that?) FAA Safety Team Maintenance Safety Tip-1404 (Great Tip) and much more.

Volume
10, Issue
10 - When Pulling a Black Box Isn't the Right Thing to Do -
by John Goglia (Very good article) Checklist Item Overlooked(Checklists are made by humans!) ‘Air Racers 3D’ Hits Select IMAX Theaters (Can't wait to see it!!!!) and much more.

Volume
10, Issue
9 - Human Error the Greatest Threat to Aviation Safety (Human error is now the principal threat to flight
safety) Mechanic Input Crucial to Success of SMS Programs
by John Goglia(The new SMS posters will hopefully help with this) Fatigue Risk Management (Interesting studies and further developments) and much more.

Volume
10, Issue
8 - FSF Releases New Fatigue Guidelines at annual
Business Aviation Safety Summit(Fatigue is a problem) First Air pilots fired after flying plane off course during
Arctic trip(Should they have been fired?) MROs have yet to embrace sharing of safety data:
FAA (Sharing can and will help avoid the same errors from occuring somewhere else!) and much more.

Volume
10, Issue
7 - MH370 tragedy shows no lesson learnt after Air
France crash, says portal (Worth a read!) Crash of USAir Flight 5050: One Unidentified
Passenger’s Story by John Goglia(Excellent Story) A Just Culture (A MUST if an SMS is going to be successful) and much more.

Volume
10, Issue
6 - Beyond Malaysia Airlines Flight MH370: 6 Other
Planes That Disappeared (And Were Never Found) (Wow!) Air traffic controller leaves control tower unattended
as Boeing 737 passenger plane comes in to land
because his relief worker was late(Was it pressure? or he says frustration) The Human Factors Ladder Still Needs to Extend
Higher (Great news but we can still do better) and much more.

Volume
10, Issue
4 - Human Error the Greatest Threat to Aviation Safety (There is more to it hen just human weaknesses) Human Factors Guide for Aviation Maintenance and
Inspection(This important guide can be found online) Pushback tractor hits jet at BWI (Ground Crew are human too!) and much more.

Volume
10, Issue
3 - To Error is Human … But Not With Aircraft (Written by our Gordon Dupont) Lessons to learn from the fatal Cork Airport accident(Fatigue played a role!) Checklist Manifesto - Book (Excellent book - worth the read!) and much more.

Volume
10, Issue
2 - Wrong-Airport Southwest Pilot Hadn't Flown to
Branson (Lack of Awareness) FBO Mechanics: Critical GA Maintenance Needs
Second Set of Eyes by John Goglia(A second set of eyes is needed) Survey highlights belief in improving safety standards (12 Challenges for Safety) and much more.

Volume
10, Issue
1 - Flying got much safer in 2013 (However, we can still get even Safer) DA: Man's death on Logan tarmac was an accident (Human Error) Don’t Bother Me with the Facts! - FAA Safety Team (Worth a Read) and much more.

Volume
9, Issue
23 Music Human factor named most likely reason for
Boeing-737 crash (It was preventable!) Call-sign confusion leads to near miss between two
Boeing 737s at Oslo Airport, Norway(Communication - or the lack of) FAA to Ground Obese Pilots Until Examined for OSA,
Pilots Fight for Rulemaking (Is this fair? or does that matter when it comes to Safety?) and much more

Volume
9, Issue
22 Music Appreciation and Maintenance Human Factors (It's an ongoing battle) When Maintenance Directions Are Subject to
Interpretation by John Goglia(Communication - you must make sure the mental pictures match) Baggage Cart Wrecks Beech 1900 (Murphy always wins!) and much more

Volume
9, Issue
21 Airline pilot secrets (Remember there is no pressure in Aviation) Pilots forgot to shut down engines before jet-blast
incident(WHY would he do that?) Airborne Screwdriver (Watch how the chain of events unravel) and much more

Volume
9, Issue
20 Safety Begins With Attitude (Attitude can determine how far you go in life) How did we get here?(Ever wonder that?) Russian Pilots sentenced to prison over fatal
accident. (Right or wrong decision?) and much more

Volume
9, Issue
19 Human Factors (Let's talk about the Dirty Dozen) Citation Crash "Unsurvivable"(But it was just a tire!) Helicopter pilot dies after accident while giving rides
at Pa. fair (Distraction - his hat was not worth his life.) and much more

Volume
9, Issue
18 Behavioral Drift Threatens Safety (Why can't they just follow the rules?) Worker Dies Just One Hour After a Near Miss(These are the free lesson! We MUST learn from them?) HNTSB Blames Pilot's Medications For Deadly 2010
Plane Crash In Tulsa - and much more

Volume
9, Issue
12 Small jet runs into hangar at Chino Airport (Human Error?) Workaround at Your Own Risk by John Goglia(Norms?) Re-Timer (Too good to be true or the best thing since sliced bread?) and much more.

Volume
9, Issue
11 Mixture Cable Failure May Have Caused Hawaii Helo
Accident (Mechanic says he is to blame but why did he make the mistake?) Cowls missing from both engines on BA A319(A technical fault?) The key to doing better work is to reflect on what went
wrong (Let's not repeat the same mistake twice) and much more.

Volume
9, Issue
10 Two Pilots Fired After Brazilian Pop Star Takes
Captain's Seat Mid-Flight (WHY would you do that?) Workarounds and AD Compliance Don’t Mix By John
Goglia(Incorrect procedures, incorrect paperwork, etc.) 5S in Aviation Maintenance - Part I (What are the 5 S's?) and much more.

Volume
9, Issue
9 Pilot Involved In Accident Admits To Alcohol Use (WHY would you do that?) Pilots sleep as flight attendant turns off autopilot on
Bangkok-Delhi flight(Fatigue or stupidity?) Stop Trying to Create a Safety Culture (Safety Cultures are nothing new) and much more.

Volume
9, Issue
7 Pilot Falls Out Of Airplane (What?) Out of the Ashes: The True Story of How One Man
Turned Tragedy into a Message of Safety(Excellent Book) More employers setting up nap rooms for weary
workers (Combating Fatigue) and much more.

Volume
9, Issue
6 Air France Crash Report: Captain Had Just One Hour
Of Sleep (He had the don't care attitude) Why Safety Deserves a Capital S(Ask Gordon Dupont) Human Error Management workshop (See you in Sweden!) and much more.

Volume
9, Issue
5 Worker Dies After Safety Warning Falls on Deaf Ears (Lack of Knowledge) Trends in Human Factors and MRM(Why do we make the decisions we do?) Air NZ: Flight safe despite pilot twice nodding off (More on the problmes with fatigue) and much more.

Volume
9, Issue
3 NTSB: Mechanic checklists a lesson in Las Vegas area
copter crash (The importance of a checklist) What Can You Do to Prevent Accidents Caused by
Worker Fatigue?(Fatigue Management) To Error is Human … But Not With Aircraft (Written by our own Gordon Dupont) and much more.

Volume
9, Issue
2 Human Factors Challenges - Part I (FAA - Dr. Bill Johnson) Safe Attitudes Make All the Difference(Safety a core value) Helicopter in 2011 East River Crash Was Too Heavy:
NTSB (How could this be? What about the Weight and Balance?) and much more.

Volume
9, Issue
1 Crashed Superjet was coded as fighter: investigators (Is this a Big deal?) Lack of training cited in fuel mix-up that brought down
helicopter(Wow - lack of knowledge) Human Factors In Action (73% of Aviation Mishaps are due to Human Error in the airforce) and much more.

Volume
8, Issue
47 - Wrong Bearing Blamed In Death Of Aircraft
Maintenance Workers (How and why would this happen?) Human Factors training is just common sense... Or is
it? (This is a MUST read) Just a Coffee Maker? by John Goglia (Thanks John, this is wonderful article) and much more.

Volume
8, Issue
46 - Tigers and Ducks (It's the little things that add up) PPE Non-Compliance Worrisome (Why would anyone NOT Comply?) A Positive Attitude Can Be Contagious, research finds (Attitude is so very, very important) and much more.

Volume
8, Issue
44 - Industrial action cloaked as aviation safety issue:
justice (Love it!) Workarounds - Part 3 (Pressure can lead to a negative Norm) Foods that fight fatigue (It is important to know everything you can about fatigue) and much more.

Volume
8, Issue
43 - Five-Year-Old Implicated In Fatal Crash (Where was the proper cockpit discipline?) Maintenance flaw led to Air Tahiti ATR engine fire (Why did they not check for tightness?) Texting in the Tower - From NASA’s Aviation Safety
Reporting Systems (Social Media is a problem in EVERY occupation) and much more.

Volume
8, Issue
42 - The "B" Nut can be Deadly (Make sure you use the right tools) Report: British pilots asleep on the job (Wow, another case of fatigue?) Workarounds - Part 2 (Pressure can play a big role in companies where norms are present) and much more.

Volume
8, Issue
41 - A Not So Routine Task (There is danger when we are complacent) Workarounds – Part I (Learn from Experience) Taking Sleeping Remedies Without Advice Increases
Health Risks (How many of us do this to combat fatigue?) and much more.

Volume
8, Issue
40 - Pilots Of Crash Plane Drunk (Why would they do that? Isn't it against the rules?) NTSB: Gulfstream Safety Culture A Factor In G650
Test Crash (A proper SMS could have or should I say would have saved lives) Think the Pilot’s Bill of Rights Doesn’t Apply to
Mechanics? Think Again. - John Goglia (This is excellent information) and much more.

Volume
8, Issue
39Evolving the Safety Culture: Leading Indicators and
Influencers (We must all strive to create the Safety Culture) Watch out for unhealthy responses to stress (You must manage stress or it will manage you) A Battle Plan for Jet Lag (This is excellent information) and much more.

Volume
8, Issue
38FAA Issues $400,000 Fine to Atlantic Southeast
Airlines (Paperwork is just as important as the work itself) Forklift truck driver fined £150 for causing £1 million
damage to aircraft(Human error on the ground) Texting While Tired (You shouldn't text and drive nor should you text and taxi an airplane) and much more.

Volume
8, Issue
37FAA Seeks GA Survey Input (Please help and take part) Sleep Apnea and Airline Safety (Sleep Apnea is more common then you think) Study Explains Why the Circadian Rhythm Affects
Health (Watch that Circadium Rhythm low) and much more.

Volume
8, Issue
36NTSB: Undocumented Modifications Led to Reno Air
Show Crash (Why would he NOT document - isn't that part of the job?) Singapore Airlines Flight 006: Human Factors Analysis (Just how many human errors were made?) FAA Announces New SMS Requirement (More on SMS) and much more.

Volume
8, Issue
35Air France 447 – Human Factors Overload (Who do you think was flying the plane, the adult or child?) Pilot's cellphone use may have been partial cause of
fatal plane crash in B.C. (Social Media IS a BIG problem) It’s Not Always Easy to Just Say No by John Goglia (Sometimes you MUST be assertive) and much more.

Volume
8, Issue
34The Potential for Greatness is Everywhere (This is so true; Greatness takes disapline, etc.) Young Drivers View Drowsy Driving as
Understandable (Lack of Awareness of the dangers of Fatigue) Watch out for unhealthy responses to stress (Dealing with excess stress is NOT easy) and much more.

Volume
8, Issue
33Engine Part Failure, Airbus Crew Distraction (Distraction is responsible for 15% of Aviation Accidents) Silver Airways flight lands at wrong W.Va. airport in
1st week of service; no one injured (Lack of Awareness) Investigators Say Boy, Age 6, May Have Pulled
Landing Gear Lever As Plane Touched Down (Lack of Knowledge) and much more.

Volume
8, Issue
27Tenth anniversary of Überlingen accident: approach to
safety has changed radically (Through this tragidy, a Safety Culture was born) Deadly Private-Plane Crashes Prompt U.S. Call for
Basics (Human Error underlies the majority of private plane accidents) To Error is Human … But Not With Aircraft (We MUST learn from our errors) and much more.

Volume
8, Issue
26What A Character! (How do yu address Human Factors in your Organization?) Flight 255 survivor to speak in documentary (video) (She was only 4 years old when she became the ONLY survivor) NTSB: Deadly 2011 Bus (Fatigue does not just effect Aviations but it effects so many others as well) and much more.

Volume
8, Issue
25Poor Disaster Response Sealed Fate of Dana Crash
Victims – Expert (Lives could have been saved, why was the response so slow?) Air France Flight 447 Investigation: Pilots Not Properly
Trained to Fly the Airbus A330? (Was it Lack of Knowledge?) "Get-there-itis" (I think we have all experienced this at one time or another in our lives - just push it to get home!) and much more.

Volume
8, Issue
24English Skills a Concern as Global Aviation Grows (Lack of Communication) 'Slip' spins drama in the skies (What was he thinking when he said that?) CDC Study Finds 30% of American Workers Sleep
Less Than Six Hours a Night(Fatigue!) and much more.

Volume
8, Issue
23Company fined over aircraft engineer's death (Safety Nets were not sufficient) Airbus A380 wing flaw undetected for a decade (Was it lack of awareness or knowledge?) An appreciation of aviation safety trends (A Thumbs Up for Human Factors Education!!!!) and much more.

Volume
8, Issue
22When The minimum Wasn’t Enough (Have you heard those words before?) Sully’ Sullenberer on being a national hero and
making a difference (A new novel worth the read) Pilot's Tip of the Week (Bullet Proof Thinking) and much more.

Volume
8, Issue
21Cause of Russian Jet Crash: Pilot Bravado? (Was it Lack of Knowledge? or was he just a Rouge? or?) Fatal '10 copter crash likely caused by improper
maintenance, NTSB says (What interfered with his judgement to cause a Maintenance Error?) Solving the Problem of Sleep-deprived Pilots (Fatigue and how to solve it) and much more.

Volume
8, Issue
20USAF to rebuild its aerospace physiology expertise (More Human Factors training needed) Patient Safety Leaders Propose 'NTSB for Healthcare' (Human Factors training is NEEDED in the Medical field) The Number One Cause of Accidents: Human Error (Would you have guess as much?) and much more.

Volume
8, Issue
19Aviation Safety Suffers Further Setback Following
Helios Conviction (Someone had to pay, correct?) Pilots’ Cockpit Argument Results In Both Being Fired (Lack of Communication and Lack of being a professional) History's deadliest plane crashes = 4904 Souls Lost (How many were caused by Human Error?) and much more.

Volume
8, Issue
18US industry voices concerns about aerospace
workforce (Lack of Resources) Mind the gap (Why having a Just Culture is so very important) Safety Begins On The Ground (How VERY true) and much more.

Volume
8, Issue
17Texts, fatigue factors in Jetstar botched landing (The Dirty Dozen attack once again) Battling the effects of pilot fatigue (Fatigue is still such a problem) Catalina crash 'due to different expectations' (I don't think the mental pictures were matching) and much more.

Volume
8, Issue
16Watchdog 'ignored complaints' on dangerous flying (At risk behaviour) The Downside of Upside Down (Was this Lack of Knowledge? You judge!) Professionalism: A ‘Must Have’ For All Aviation
Workers (Not just the pilots but EVERYONE) and much more.

Volume
8, Issue
15Boeing worker trapped under 787 leaves hospital (He tripped and fell) United Kingdom: New scheme takes off to cut airside
accident (Health & Safety on the ramp) Lack of de-icing likely caused Russian plane crash (Why would they make that decision?) and much more.

Volume
8, Issue
13Continental To Appeal Manslaughter Verdict In
Concorde Accident (New Evidence) DGCA asks airlines to fix work hours for maintenance
staff (A form of fatigue management) Living and Working With the Reality of Risk (There is RISK in everything we do) much more.

Volume
8, Issue
12It's plane nuts! Jet plowed into work truck parked too
close to taxiway and driver AND airline sue (He didn't think it would hit) High School Students Test Best with 7 Hours' Rest (REST is benefitial for everyone) Warning Signs of Fatigue (Excellent Poster) much more.

Volume
8, Issue
10 Dirty Dozen: Counteracting Complacency (Complaceny is everywhere)Do It Right The First Time! (Anything worth doing is worth doing it right the first time) LA Look at World Air Traffic From a Satellite Over a 24
Hour Period (This is really incredible) much more.

Volume
8, Issue
9US Airways airport worker dies in 'tragic accident' in
Phoenix (What could have caused this tragic accident?) DGCA asks airlines to fix work hours for maintenance
staff (A form of fatigue management) Living and Working With the Reality of Risk (There is RISK in everything we do) much more.

Volume
8, Issue
7NTSB Faults Cessna and FAA in Tailcone Icing (Lack of Awareness on the FAA's part) “He Yelled at Me to Stop!” (Murphy's Law) Safety is never an issue – until there is an “issue” (They often find that Human Factors played a part!) much more.

Volume
8, Issue
4General Aviation Accident, Fatality Rates Drop in 2010 (We still have to thrive to be better) Airlines run up a safety debt?(Air travel will continue to grow) It’s Time to Renew Our Commitment to Safety (No one needs to die in an accident) and much more.

Volume
8, Issue
2 2011 shaping up to be 'safest ever' year for fliers (We MUST continue to strive for "Safer" planes) How would you paint your Dreamliner?(Cute, interactive link - try it!) 8 Ways To A Healthier Workday (How many of these do you do?) and much more.

Volume 7, Issue
45China Eastern Airlines to improve English after safety
breach (Lack of Communication) Fashion Model Mangled by Airplane Propeller is
Among Hundreds Injured in Aviation (We NEED to put Safety Nets in place) 2011 safest year for air travel since 1945 (This is great but we must always strive to make aviation ALARP)and much more

Volume 7, Issue
44Office of Aviation Medicine (Fatigue, not just pilots and maintenance. What about the Flight Attendants?) Energy Crisis (Energy drinks, coffee, water - which is best?) 10 FACTS ABOUT DRINKING & DRIVING (Pay attention as many people push the limits)and much more

Volume 7, Issue
43North Sea helicopter crash report says gearbox failed
after maintenance error (Was it Lack of Communication, Lack or Awareness or ? How many of the Dirty Dozen preconditions can you see? TOO MANY!) Pull the String (Very motivating!) Fatigue risk scheme considered for controllers (Fatigue Managment is so important for EVERYONE)and much more

Volume 7, Issue
42Does Common Sense Have a Mathematical Formula? (Interesting and well worth the read) “CAUTION!” DO NOT IGNORE A “CAUTION” IN THE
PUB! (Great Advice) When All Else Fails... (Oh yes, Murphy is alive and well)and much more

Volume 7, Issue
41No Mechanic Is an Island - As the Wrench Turns by
John Goglia (Communication is so very, very important) Pilot who had been drinking gets six months in prison (What was he thinking? and why would he be so stupid?) Pilots: Canadian SMS Proven Aviation Safety Tool (SMS will save lives)and much more

Volume 7, Issue
40The Downside of Upside Down (Instructions must be clear and consise) FAASTeam Maintenance Safety Tip (Don't forget your Human Factors checklist) Aviation Safety is a Team Sport (Teamwork is a MUST)and much more

Volume 7, Issue
39Fighting Pilot Fatigue on Military Charter Flights (Fatigue again, it's difficult to manage) US Airway’ Take 5 Approach (Distraction) New Human Factors Recurrent Course for Instructors
to be Available in 2012 (Call System Safety Services and we would be pleased to help you with your reccurent training)and much more

Volume 7, Issue
37 Navigator in Russian Crash Was Drunk, Report Says (Drinking and other human errors were all preventable) Families Push Obama on Pilot Fatigue Rules (We MUST have rules to help us deal with fatigue) Maintenance Standards: Why so high? (When we make a mistake, we have the ability to kill many people)and much more

Volume 7, Issue
36 Pilot of jet in 2005 Teterboro crash sentenced to 6
months (Did he deserve prison time?) LoPresti Set To Roll Out Unpressurized Tires (Is this a Safety Net?) The APP that helps you sleep like a baby (More help in the battle of fatigue)and much more

Volume 7, Issue
35 French Accident Bureau Convenes AF447 Human
Factors Group (Why did they do what they did?) Concern in the cockpit: Does autopilot = rusty pilots? (Do they lack skills?) Fainting worker Sarah Maroney sues Qantas for
almost $270,000 (Lack of Resources led to fatigue and fainting)and much more

Volume 7, Issue
34 NATA Puts Safety Training Programs Online (Available anytime, anywhere) Bone Tired? Make It Through The Day (Tips on how to deal with fatigue when it happens) Depression Rates More Common in High-Income
Countries, Study Says (Very interesting study)and much more.

Volume 7, Issue
33 The Magic of Mentoring (We can ALWAYS learn from others experiences) 'Macho attitudes' a danger for pilots (A rogue pilot, get-there-itis, pressure, etc can all lead to accidents) Checklist conundrum offers no easy answers (Complaceny can lead to you NOT using the checklist correctly or sometimes not at all)and much more.

Volume 7, Issue
32 Showing How Worker Fatigue Hurts the Bottom Line (There are so many dangers that come with fatigue) Safety booklet for pilots takes off (Highlighting the key Safety issues) Beating the Post-Vacation Blues (Now that summer is almost over, many of us are heading back to work) and much more.

Volume 7, Issue
31 Sleeping in the Daytime (Managing Fatigue especially when shift work is a reality) Sleep Type Predicts Day and Night Batting Averages
of Major League Baseball Players (Interesting states) National park deaths: Random or reckless?(Oh yes, we know all too well about Reckless behaviour) and much more.

Volume 7, Issue
30 NTSB releases Ludington plane crash photos,
documents; Fuel system debris is focus of much of
the probe (How did that get in the fuel?) Jeju Air criticized for pilot error (Believe it or not, pilots are human too) “I Ain’t Gonna Do This Stuff”(With a Human Factors workshop, you get out what you are willing to put in) and much more.

Volume 7, Issue
29 Build a Trust Fund (Trust and Safety go hand in hand) Beware The Icing Hazards Masked By Average Droplet
Size, Scientists Warn (Interesting) Study: even one glass of beer, wine boosts car crash
risk (Should we be adopting the drinking laws of Sweden?) and much more.

Volume 7, Issue
27 Would Pilot 'Panic Button' Save the Day or Tie Hands? (What happens to the human?) $243,360 in Fines Issued to Maine Contractor for Fall
Hazards (Protective measures are in place but it takes the human to make them work) Cell Phone: Weapon of Mass Distraction (You can't use a cell while driving a car but what about while working on a plane?) and much more.

Volume 7, Issue
26 Aviation Issues On NTSB 'Most Wanted' List (How many of these do you think involve Human Error?) Distracted Driver (EVERY human can get distracted) Corporate aviation safety management systems - a case study (Are you eating the right foods at night?) and much more.

Volume 7, Issue
25 Inattention led to plane's door opening in flight -
report (But I thought I had followed procedure!) FAASTeam Maintenance Safety Tip (Training is ALWAYS a Safety Net) Night Shift Nugget (Are you eating the right foods at night?) and much more.

Volume 7, Issue
24 Fit for Work? (You may have had lots of time off work and lots of sleep but how do you know if you are Fit for Work?) Fit for Work Indicatior Opportunity (Here is your chance to try this New, Inventive system for 6 months) Pilot's bereavement 'crash factor' (His mind was just not on his job and the FFW would have likely picked that up) and much more.

Volume 7, Issue
23 From The FAA: SMS: What It Means for the AMT? (Sweat the small stuff and you avoid sweating the big stuff) Alaska Airlines replacing paper manuals with iPad (Much easier on the back) Sleep Problems Lead to Other Problems (You develop a I don't care attitude) and much more.

Volume 7, Issue
21 How alarming are Airport Ramp Accidents? (You mean ground crew are humans too?) FAA expresses concern over Technician Fatigue (It's about time the world woke up and paid attention to fatigue) 25 Signs you might be safety Geek (Stress is an occupational hazard) and much more.

Volume 7, Issue 18 Aircraft
Maintenance Duty Time Limits
(Until June 13th, you can tell us your opinion) Solution for fatigued aviation workers eludes FAA
(Fatigue is on the forefront) Human factors
to blame for fatal crash of Air India Express flight from Dubai
(How many of the Dirty Dozen preconditions can you see?) and much more.

Volume 7, Issue
16PNG death crash pilot 'drunk with
fatigue
(Time and time again fatigue is the issue) Flight-Deck Basics is also Ramp Basics (Flight-deck Crew and Ramp Crew are both human) FAA Mandates Controller Wake-Up Calls (Read
what the FAA's "interim" plan to deal with fatigue is) and much more.

Volume 7, Issue
15'AI ignored safety rules during fire'
(What interfered with his judgment at the critical moment?) FAASTeam Maintenance Safety Tip March 2011 (Let's talk about Pressure - there is NO Pressure in
Aviation is there?) Five Ways to Make the Most From The Mistakes You
Make (We all make mistakes but with every
mistakes comes something we can learn from) and much more.

Volume 7, Issue
14United Plane Flew Despite Smoke, Fumes
in Cockpit
(Why would they let the airplane fly? Was it Lack of Awareness? - You
decide!) Reagan air traffic incident renews fatigue debate (Fatigue raises it's ugly head again) NTSB Cites Fatigue, Poor Training In Fatal Crash (Fatigue,
Lack of Teamwork and Lack of Communication - these factors all played a part
in his decision that killed all on board) and much more.

Volume 7, Issue
13 NTSB challenges FAA for access to
incident reports
(We can all learn from incident reports so why can't we all get along?) OSHA timeline highlights 40 years of healthier
workers, safer workplaces and a stronger America (This is fantastic!) Vibrating cockpit seat proposed for pilot alerts
(This could be a great Safety Net for pilots - what do
you think?) and much more.

Volume 7, Issue
12
As the Wrench Turns: Trapped Inside the Cargo Hold by John Goglia
(Human factors everywhere, can you spot them?) Read Any Good Logbooks Lately? (How important written communication is!) Reflections After an Accident (Humans love to gamble - and sometimes it just doesn't
pay off) and much more.

Volume 7, Issue
11
Return to service
(Pilots and Maintenance are all part of the same team) A Safety Management Perspective (Risk
Assessment) Drowsy Surgeons Should Inform Patients (Fatigue Management is not only important in our
industry) and much more.

Volume 7, Issue 62011 William (Bill)
O'Brien Aviation Maintenance Technician Awards Program
(Recognition and Awards for Mechanics - do you know anyone whom qualifies?) Shaping Professionalism and Integrity in Aircraft Maintenance (Lack
of Resources - HE HAD the best of intentions) 10 Decisions to Help Make 2011 Your Best Year Ever
(How to make 2011 the BEST!!!) and much more.

Volume
7, Issue
3 Lessons Learned From Maintenance
Mergers
(There are many Human Factor Issue to consider - and how do you deal with
them?) Language Lessons (Communication so
VERY, VERY important) Another near-accident as planes land on wrong track
at Ovda Airport (Poor Lighting?) and much more.

Volume
7, Issue
2 Situational Awareness in
Maintenance
(Distraction - Read and watch the links of this accident and see how easily
they form) Survey: Why Aren't More Women In
Aviation? (yeah, why aren't they?) A Virtual Tour of the A380 (Wow, what a plane but when will it be ready?) and much more.

Volume 6, Issue
43An eBook dedicated to the founder of the Dirty Dozen
by Charles Alday. Learning human factors from the pipeline industry
(This book is a MUST read for anyone with interest in Human Factors) Airlines' lessons in safety for oil industry
(Avoid complacency: "The assumption that safety is 'good enough' can only
lead
to disaster.")
QUESTION: What percentage of fatal car crashes involve a drowsy
driver? (Fatigue - how we underestimate our ability to deal with it) and much more.

Volume 6, Issue
42
Cream and sugar with your jet fuel? Plane water tanks mistakenly filled
(Ground Crew are Humans Too and are such subject to Human Error) NTSB Reports Fuel Exhaustion In 2009 Greenville Accident
(Lack of Awareness and Lack of Communication)
NTSB: Delta Pilot Was 'Fatigued' During Taxiway Landing
(Fatigue - how we underestimate our ability to deal with it) and much more. Thank you Roger for another year of amazing Aviation
HF Newsletters that have inspired each and everyone of us!

Volume 6, Issue
41
FAA Proposes Safety Management Systems For Airlines
(SMS is important for EVERYONE, not just the little guys but the airlines as
well!) FAASafety.gov
(Human Factors in Aviation study)
Drowsy Driving Prevention Week® Highlights Prevalent and Preventable
Accidents (Driving or flying Drowsy is
DEADLEY) and much more.

Volume 6, Issue
40
The Human Relay: Fully Energized
(Why it's so important to follow procedure) I’m a New Supervisor, Now What! - Lessons Learned from John Goglia
(To be a Supervisor, you must first be trained in how to be one)
Air India plane crash: 'Sleepy' pilot blamed (Fatigue
does it again) and much more.

Volume 6, Issue
39
Air controller 'fatigue threat'
(Fatigue talked about so often because it is so important) Young woman becomes first Aircraft Maintenance Engineer
(Women are human too, believe it or not?)
Aerobic Exercise Relieves Insomnia (Exercise
is so very important and is closely related with fatigue) and much more.

Volume 6, Issue
38
New Products on the FAA Maintenance Fatigue Website
(Fatigue Management is so very important and WILL save lives) Baker’s Dozen
(Attitude can make or break each and everyone of us as well as the attitude
of your organization)
Human Factors in Aviation Communication (Communication
is all so important) and much more.

Volume 6, Issue
37
SHELL Model is the foundation to understanding Human Factors in Aircraft
Maintenance
(Creating Awareness)
Flight Stress
(All to common in our industry - good read)
An Appetite for Life (Courage and
Determination - truly and inspiring story) and much more.

Volume 6, Issue
34
Dirty Dozen: Lack of Communication
(Happens all too often)
Is there a perfect time to take a nap?
(Fatigue)
Shift Start Times Impact Sleep and Alertness (More
on fatigue) and much more.

Volume 6, Issue
33
New Release of MX Fatigue Newsletter
(Learn more about Fatigue) Bad Regulation—You Can Initiate Change
(Learn to be assertive when things don't seem right)
Lessons of Manchester runway fire (Every
Accident has a lesson) and much more.

Volume 6, Issue
32
Congress Passes Safety Management Law
(Safety Management Systems) FATIGUE ACCIDENT/INCIDENT CAUSATION TESTING SYSTEM (FACTS)
(Fatigue)
How to Get Control Of Your Time and Your Life
(Time is Life) and much more.

Volume 6, Issue
31
Plane Loses Engine Cover After Indianapolis Takeoff
(Maintenance Issue) The FAA Safety Team (FAASTeam)
(Important Update)
New Guidelines Tell Co-Pilots to Speak Up
(Learn how to be Assertive) and much more.

Volume 6, Issue
30
Five Benefits of a Near-Miss Reporting Culture
(SMS)
Make Reporting a Daily Event
(Great Idea)
Recovery sleep’ can make up for lost ZZZs
(Fatigue) and much more.

Volume 6, Issue 28
Firm Reveals Ingredients for Successful Shiftworkers
(So Important to understand Shiftwork) Summer Heat is a Real Safety Concern (Heat can be deadly)
The Human Contribution
(A must read on Human Factors) and much more.

Volume 6, Issue 27
A Human Error Slip. Good Plan Poorly Executed (Lack
of Awareness) 'FAircraft
maintenance errors, FAR violations and using the Aviation Safety Reporting
System (ASRS)
(A must in a SMS)
Feds: Captain could have prevented Denver accident
(Could this be stress, Complacency or was it both?) and much more.

Volume 6, Issue 24
NTSB Warned That Future Pilots May Not Be Up To
Snuff (Lack
of Knowledge) FAA Publishes Advance Notice
of Proposed Rulemaking On SMS (Lack of Knowledge or was it
awareness, you decide)
PRESSURE
(#8 of the Dirty Dozen ) and much more.

Volume 6, Issue 23
Landing gear mishap spurs NTSB recommendations for maintenance training(Lack
of Knowledge) Pilot Claims Her Bell 47D1
Manual Contained Improper
Instructions (Lack of Knowledge or was it
awareness, you decide)
Delays in anti-pilot fatigue rules criticized
(More on this important subject of fatigure) and much more. Thank you again Roger for all your hard work and thank
you for sharing it with all of us!

Volume
6, Issue 22
IMAX 3-D 'Legends Of Flight' Set For June Premier(This
is a MUST see) Interrupting a Nurse Makes
Medication Errors More Likely (Distraction
occurs in Every Industry)
Six Ways to Avoid Misunderstandings
(Communication (a 2-way street) is so very, very important) and much more.

Volume
6, Issue 21 When the
Maintenance Manual is Wrong(Get
it corrected, Be assertive) Evidence
Surfaces Of Passengers In The Cockpit Of Polish Airliner Which Crashed (Pressure
to get there)
Concorde crash trial: Continental Airlines to make final plea
(The ONLY reason for discipline is to ensure that the error never happens
again) and much more.

Volume
6, Issue 20 Failure to Communicate (It's
a 2 way street) Broadcast Safety
Improvements (Improve your Safety Culture)
ATSAP Program Shows High Number Of Air Traffic Errors (It
is so important to report errors) To Sleep with Spouse or Not (Fatigue?) and much
more.

Volume 6, Issue 9 NATIONAL SLEEP AWARENESS WEEK
(Fatigue)
Aviation safety rate: One accident for every 1.4 million flights (Training
Pays Off)
Accident: ABX Air Cargo B762 at San Francisco on Jun 28th 2008, on fire
while parked, no arson (Lack of Awareness)
and more..

Volume 6, Issue 8 Air Methods Exits Level 1 FAA Safety
Management System Status (SMS)Doctors' skill checks need
upgrade, says Burnham (Pressure)
Here are 10 small steps to get you on the road to better health in 2010
(Always good to know)
and more.. Again I
would like to give a big Thank You to Mr. Roger Hughes as without him these
EXCELLENT Newsletter would not be possible.

Volume 5, Issue 37
Air crash museums keep dark memories alive
(Excellent way to preserve life)
Under Pressure
(pressure and how to deal with it)
How do I know when fatigue is affecting my performance? (This
is a important read) and more... Once again, thanks Roger!

Volume 5, Issue 36Welcome
to the FAA’s Maintenance (MX) FATIGUE section
(Excellent for anyone interested in Fatigue)
Qantas safety fears as engineers vote work ban
(more on Fatigue - get the idea of how
IMPORTANT this subject is?)
AEA Says Safety Management Systems Unwieldy(SMS) and much much more

Volume 5, Issue 34
Human Factors Training is just common sense, or is it?(Great
author)
Cockpit Interruptions and Distractions
(Distraction)Control and Actuator Locks/Pins -
FAASTeam Maintenance Safety Tip
(Safety Net)
Best Practices! and much much more.

Volume 5, Issue 33 Pilots,
Airlines Push For Nap Time (Fatigue)
Human Factors: Beyond the "Dirty Dozen" - Part IV
(Excellent)Sleep Myths and the Truth: Snoring
(More on Fatigue - this is an important article to read) Top 5 Causes of Motor Vehicle Crashes (Human
Factors can affect motor vehicles too!) and much much more.

Volume 5, Issue
28 American Airlines caught in
drug sting (Not Fit to Work)
A Near-Miss - “Red Flags” Not Heeded. (U.S. Navy) (The child at work)
Controlling Consequences of Errors Through
Assertiveness (The Title Says it all)
Overlooked trim led to 737's post-V1 abort(Distraction) and much much more. Great job Roger and thanks

Volume 5, Issue
27 Post Article Examines "Crash
Pads" (Another solution to Fatigue?)
Post Maintenance Flights are Critical (It's all about the metal attitude )
Human Factors: Beyond the Dirty Dozen - Part I (A MUST READ)
True Leadership different from culture of command (Different cultures) and much much more. Another fantastic job Roger and thanks

Volume 5, Issue
26 Mech magazine - US Navy Mishaps
(Worth
reading as they are human to)
Developing a Safety Management System (The next step to reducing Human Error)
Naha jet fire laid to faulty Maintenance (For want of a washer - an aircraft was lost)
Human Factor Techniques to survive a downturn
(This is a must read) and much much more. Great job Roger and thanks

Volume 5, Issue 18NTSB’s Rosenker discusses FAA’s role in oversight
of commercial air carriers. Everyday survival: Why smart people do stupid
things. (Good question but you have to
buy the book to get the answer) Improving assertive behavior.
(We can
always use more of that) Midnight shift
nugget. (These are always valuable)
And lots more.

Volume 5, Issue 17Computer Failures are
probed in jet crash. (We humans aren’t
the only things to fail or did we contribute?) Maintenance error caused Ohio plane crash. (Once more)
FAA Safety alert focuses on tire pressure. (Go to Safety videos, #1- “Death of an Airline”
case study to see what one low tire can do)Gas
trimmer torches C-182. Diligence in Mundane things. And much more

Volume 5, Issue 16Ramp design error a setback
for remodeled airport. (3 ft. is a big
human error) Fall proves fatal to FAA
employee. Engine on Navy E-6 sets military aviation record. (If only we human could be a reliable)
This is the best I have ever heard on “life explained.”
(Well worth reading)
And much more. Great job Roger.

Volume 5, Issue 15Congressmen act on English
speaking airplane mechanics. (Good)
Safety glasses save AMT’s eyesight.
(That’s what they are for) Maintenance
Mishap summary. (An error caught before
it could kill) Whack-A-Mole. (This
is a great book that I highly recommend written by a dedicated industry
Safety expert) And lots more.

Volume 5, Issue 13 Report critiques FAA
Oversight of aviation safety action program. (Still a great Safety tool) Remember Flight 191. Woman excels in man’s world
of aircraft mechanics. (Women are only
2% of the maintenance workforce)
Clogged fuel filter and poor inspection causes of fatal Millville airplane
crash. (Proper maintenance and this
would not have happening) Worker falls
to his death at Miami International Airport. (This should not be happening)
And lots more

Volume 5, Issue 10THY 737 altimeter fault
occurred several times before crash. (Maintenance likely contributed here)
Proud member of the “Dirty Dozen” – Lack of Communication. Safety More than
just rules. (Fatigue is in there)
Real life tips for improving alertness on the night shift (These are all helpful)
and much more

Volume 5, Issue 9PHX Dash 8 Mishap - GPU vs. Prop.
(Everyone lost but no one hurt)
"Tailstrike" may write off A340. (Did
Fatigue play a role? See next article) Pilot
"barely slept" day before Emirates near-disaster. Mechanic charged with
falsifying FAA credentials. (He was never an AMT) Probe into Virgin A340 bar
fire finds wire protection missing. (Likely
for a long time and no one noticed) and much
more. First Class. Thanks Roger

Volume 5 Issue 8 Cockpit Fire Damage ASA
Bombardier CRJ-200. (Not lightning like
most of the articles and pictures on the internet suggest)
American Airlines made mistakes before. (The Maintenance Dirty Dozen strikes again)
Loose Fastener Causes Control Disconnect. (Out of date manuals played a big role = 4 dead)
Procedural Error and Non-compliance in
Maintenance. (The title says it all) and much more.

Volume 5 Issue
7Tunisian pilot who prayed as his plane went down jailed in Italy.
(The mechanics who made a honest mistake got 8 years)
Study finds criminal prosecution following accidents damages safety. (This is so true but revenge for the error is the
norm in our society) Accident: Arrow Cargo
DC10 dropped parts of engine on houses. (Not due to a Maintenance Error I hope) and
lots more. GREAT job Roger.

Volume 5 Issue
5The real good
news is that Roger is back and you'll see a BIG improvement in layout and
content. THANKS Roger for the great work. ANZ
Highlights Evidence of Sensor Failure on Crashed A320 (The big question will be what, if any,
role did maintenance play?) Mechanics
Error Cited in Fatal Crash.
(Our worst nightmare)
BA Ground Workers Charged in A320 Hit-And -Run.
(What is the company culture that might
encourage that decision?) NTSB Blames 747
Flight Crew for 2005 Nose Gear Accident. Fatigue Factor in B737 Runway
Excursion. (We keep underestimating its
effects) Breakfast - Don't Leave Home
Without it. And much more.

Volume 5 Issue
4Report Says
Mechanics Missing in Human Factors Efforts.
(We can sure help there)
EMB-110 Down in Brazil's Amazon Basin.
Lawsuit Filed in January 29 Seneca Downing.
(A major hazard of our profession)
Qantas Fires Another Fake Engineer.
(What people won't do to get into our
profession) Cessna Mechanic Caught
Stealing Parts, Selling Them on EBay.
(Not the way to supplement your income)
and more including a cartoon at the end

Volume 5 Issue 3FAA
Applauds Agreement that Reinstates the Aviation Safety Action Program
(ASAP). (Now that is GOOD news)
Airman looses 115 Pounds in Order to Work on aircraft. (More GOOD news. Our industry could use a few more
with this level of dedication) Sailor's
Families Want Answers in Helicopter Accident. (Sadly, likely maintenance played a role)
Too Many Emails Fog the Brain. [Now I have
an excuse for foggy brain) And much more. Be
sure to check the pictures at the end.

Volume 5 Issue 2The good news is that Roger will be back soon.
Aircraft damaged in hit and run incident. (Likely a "Blame Culture" behind this one)
First
flights from Baghdad to the EU. (Good news
but not my vacation choice yet) Northrop
Grumman sued over Mallard crash. (60 years
and the lawyers can still come after you)
Military controller's trial a lesson in tea totaling. (Can't even trust tea to drink) And more

Volume
5 Issue 1 1.5 Billion people fly
without a fatality. (That's the good news)
French Concorde crash manslaughter
trail to begin in Feb. 2010. (The bad news
as it will do NOTHING to advance aviation Safety)
Manslaughter charges filed against fire people. (More of the same - Revenge)
First lawsuit surfaces in wake of PHI s-76 crash.
(This one is for money) Cessna to slash
2,000 more jobs. (That's a lot of people,
some who will not come back to our industry)
and more
2009
May
everyone have a Safe, Healthy and Happy 2009(And WOW; Over four years of aviation
Human Factors news here)

Volume
4 Issue 48Misconfigured A330
flight computers led to severe hard landing. (Maintenance error installed the wrong box -Some
Murphy-proofing needed here) Investigators
look at recent paint job in ANZ accident. (But after 2 hrs flying?)
NTSB: Wake
turbulence from 767 likely caused Mexican Lear crash. (The invisible killer)
Judge who coined famous phrase to get Safety award. (sadly,it can be used on more than just this accident)
Don't take chances with hydraulics. (Skydrol
in the eye really smarts - I know first hand)
and much more.

Volume
4 Issue 46In Memoriam: William
F. O'Brien. (Aviation has lost a great
mentor for Safety) NTSB Issues update on near collision. (10 ft is waay too close)
Police Investigation Assigns blame for plane crash that killed 199.
(This will do nothing to prevent a
reoccurrence) Fatal air crash report points
finger at Transport Canada. (Sadly
they are often an early link in the chain of events that lead to the
accident) Coroner attacks systemic
failures that led to 10 deaths. (More early
links) and a lot more as always.

Volume
4 Issue 44Cyprus to
prosecute five people over airplane crash in 2005. (Revenge that will do nothing to advance aviation
Safety) Accident reports should include
mechanic's details. (They do it for pilots)
Broken trim tab causes severe
vibration (That vibration can also lead to
loss of flight control and aircraft) Lack of
Resources. (Our "can do" attitude can get
us into trouble) NTSB wants Safer
medical flights. (Don't we all)
Learn and Earn. (After reading this go to
the "Death of an Airline" training video case study)
and, as always, much much more.

Volume
4 Issue 43Your personal
contribution to Safety. (We all have a
vital role to play) Required reading.(It
is) NTSB issues update on business jet
accident in South Carolina. (Did
maintenance contribute to the tire failure?) Active
listening during shift turnover/handovers. (And any other time) Ten worst
aviation disasters in history (Human error
played a role in each one) and much
more as always.

Volume
4 Issue 41 Mechanics face
manslaughter charge for Madrid air crash. (I hope they aren't going to become convenient scapegoats)
Medical helicopter crash: It has happened again.
(Once is too many times) Jet fire
under investigation - Update.Update: Oxygen
bottle ruptured Qantas 747. (That could
have easily been a lot worse) You're Safer
on a plane. (Interesting stats that make
hospital visits scary) and much much more.

Volume
4 Issue 40 Man hospitalized after
airport fire. (A maintenance test gone
wrong) Pilot Error not to blame for Madrid
air crash. (Sadly, the human will be in
there somewhere) Leaking hydraulic line
sparked Osprey fire. (Not the first time
that has occurred) TSB finds 8 factors in
crash (This one is real close to home)
Lack of Awareness and Teamwork. (A human error with a happy ending - no accident)
and much more as always. Thanks Roger.

Volume
4 Issue 39Qantas engineer's false safety checks.
Qantas baggage handlers sue over work injuries. (Both not the headlines any company wants)
Airline maintenance cuts "threaten safety." (The ole try & save now but pay a lot more later)
5 things you didn't know: Plane crash.
(Very interesting; specially the odds)
No more blame & shame (The medical are
learning from us) and much more.

Volume
4 Issue 36Aircraft mechanic gets prison
for fraud. (Well deserved)
Qantas pilots seek role in maintenance.
(They have one - report problems) Madrid air
crash investigators explore "pilot error" possibility. (But did maintenance set them up with no warning
horn?) When a tragedy becomes a crime.
(This does nothing to advance aviation
Safety but promotes the "revenge mentality.")
Some great stuff on the worse of the dirty dozen - Fatigue and much more.

Volume
4 Issue 34 Regulators seek $18,000 penalty for United.
(That's an expensive maintenance error)
Crash of Itek Air B 737. (They were banned from Europe for a reason) Spanair crash probe update. Air tour
Maintenance. (Lack of Knowledge can be
deadly) Geography lesson for pilots and
travelers. (This is worth going to)
More sleep equals fewer mistakes for hospital interns. (Note their hours of work)
and much more as always.

Volume
4 Issue 33 Cargo door opened in flight.
(Not a reason to die but they did)
Pilots furious over TSA damaged airplanes. (So would I be) Crash of Spanair MD82.
(Sure hope that maintenance didn't
contribute to those 153 deaths) Safety
concerns about European airlines. (90% of
snags occur on the final flight of the day - get-home-itis?)
and lots more including the usual midnight sleep nugget. Great work Roger!

Volume
4 Issue 32 Maintenance
Brotherhood. (That is a display of
professionalism to a fellow professional) US
Airways employee dies in mishap. Fatigue continues to cause accidents.
(Fatigue is easily the #1 of the dirty
dozen contributing factors to human error)
Identifying who survives disasters - and why. (The secret? Being mentally prepared)
Why do doctors kill more people than airline pilots? (Hospitals are 33,000 times more dangerous than
flying) and much much more.

Volume
4 Issue 29 Inquest. (Another unnecessary death)
Sweat the small stuff. (The secret to a
successful SMS) Crew believed that the gear
was down. (Saved by a "gut-feeling")
Dual engine failure cited in B 747 crash.
(Maintenance or Pilot or both error?)
Hospitals work to cure errors. (They're human also) and much more.
(Great work Roger; Thanks
for sharing)

Volume
4 Issue 28 US seeks to improve
runway Safety. (Great idea. Traffic lights
for aircraft) Kalitta engine fire. (Maintenance or lack of?) NTSB Safety recommendations. (All for these) From
nose to tail. (All to easy to do)
FAA multimedia tools for human factors presentations. (A real good start and the price is right) American spends $20,000 per minute on jet fuel. (Wow. Won't complain so much when I fill up)
and much more

Volume
4 Issue 26 Continental to stand
trial for Concorde crash. (That will be a
lawyer orgy) Nosegear collapses during
towing. (Miscommunication with ground crew
that will be very expensive and very avoidable) SMS on horizon in aviation industry. (Done right, it will further lower our accident rate)
Workplace. (An interesting article)
Napping. (The Power Nap - A must read and
heed) and much more.

Volume
4 Issue 25 Maintenance needs Professional
Standards. (I agree with John Goglia there)
Navy maintenance mishap. (Add bullets to
your daily hazards) Ten most tragic
celebrity air accidents. (Who can forget
the day the music died) Do not mix
oxygen & oil. (The picture tells it all)
and lots of other great information thanks
to Roger and jetBlue

Volume 4
Issue 24 Mechanic dies in
engine accident. (Not a good way to end ones
career) NWA mechanics at fault in cowl
incident. (Why did the pilots continue the
flight?) FAA told to address crew
fatigue. (Long overdue)
Sudan crash probe underway and much more.

Volume 4 Issue 21Mishap ruins new chopper. (And someone's career?)
747 crashes on take off. (Lucky no
fire or injuries) Tragedy won't be repeated.
(Wonderful when we actually learn from our
mistakes) And much more

Volume
4 Issue 20 Missing bolt causes nosegear
up landing. (Another human error)
Navy Maintenance mishap summary. (Forgotten
tools are a universal problem) US DOT calls
for better FAA/Airline coordination on AD compliance. (Thousands of passengers would agree with that and so
would I) Criminalizing air accidents
blocks air Safety. Don't let a hospital kill you. (This is a must read)
And much more.

Volume
4 Issue 18AMT day passes house. (One step closer to well deserved reality)
Time pressure situation. (Easy to do and easy to prevent) Community service for crash manslaughter. (Appropriate for a non criminal act)
Danger on the ground. (With my $200 car GPS
accurate within 10 feet why do we have runway incursions?)
Safety Medical Organization adopts Aviation methods to reduce errors. (I'm all for that)
and a lot more good stuff. Thanks Roger.

Volume
4 Issue 15 French
prosecutors want to charge Continental employees with manslaughter. (Revenge or to be seen to be doing something?)
Inquiry looks at FAA actions after mechanic killed.
NTSB aviation accident statistics. (We now
kill more mechanics than passengers)
Tire falls from helicopter. (They make
cartoons about this) Fatigue can be fatal.
Employee killed on ramp. Top 10 most dangerous jobs (Check out # 2 and take up mining)) and much much more.

Volume
4 Issue 14 Mechanic dies. Qantas
worker dies. (We work in a dangerous
industry where one misstep can be your last)
Offside ASRS report. (Maintenance can cause
runway incursions as well as pilots) Can
airport nightmare happen here? (This is a
must read for all Canadians - and I like to think the answer is no)
Just Culture system for nurses and much much more.

Volume
4 Issue 13Classic traps.
(The forget the unimportant washer trap)
Adam Air final report. (It resembles
Eastern Flight 401 all over) Brake problems
led to skid. (Crossed wires usually end in
unwelcome surprises) Canadian crash court
attacks airline culture. (It's always there
in the background) Sound effects.
(If you snore or know someone who does read
this one) and lots more. Great stuff Roger. Thanks

Volume
4 Issue 12Man
killed didn't follow the rules. (Rules are
there to act as Safety Nets to keep you alive)
Pilots possibility asleep during Hawaii flight. (If you are fatigued, eventually you will sleep and it
may not be when you want to) NTSB
tired of inaction on fatigue. (So am I)
Parts left behind. (Maintenance will take a
hit for that delay) Toyota develop a jet?
(If so it will likely be reliable) and much more.

Volume
4 Issue 11 Crossed wires cause
accident. (Easy to do and can be hard to
detect) Airline reviews maintenance. (So would I with a 10 million fine hanging over
my head) Manslaughter and negligence
sentences upheld. (When 118 people die,
they just have to blame someone) How to
minimize jet lag. (Teleconferencing?)
And much more on Fatigue our # 1 enemy and more.

Volume
4 Issue 10Tissue's the
issue. (Amazing how simple things can have
grave consequences) Falling piece was
aircraft maintenance device. (Just be glad
that it didn't kill someone) FAA criticized
in report on airplane parts. FAA proposes record $10 million fine. (That's a lot of money for an error that they
reported on themselves) Help wanted:
Airplane mechanics. (I wonder why??
My son earns more as an auto body repairman and has never had to work
midnights) and much more including more info
on Fatigue.

Volume
4 Issue 9DC-9 runs amok.
(Not the first time that has happened)
Hurry up errors. Jet slides off
runway. Venezuela plane crash leaves 46 dead. Pilot fired for
buzzing airport. All clear given prematurely. (It was not all clear)
Safety procedures not followed. (even
trains can kill) and much more.

Volume
4 Issue 8Poor maintenance causes fatal
helicopter crash. (Pity that it so often
takes a crash to discover this)
Airline suspends pilots who over flew airport. (When the body says you are going to sleep, you will)
Qantas Safety record under threat. (This is
publicity that no airline wants) Fasten
your seatbelt. (Check out the survival
seating chart) And a lot more.

Volume 4 Issue 7ATR accident report. (Stores contributed to this one along with a lot of others)
Dangerous planes flew for years. (Maintenance sure contributed to this one)
Icing linked to crash. (Way too soon to
tell) Demand for better aircraft
maintenance. (All for that) Human error causes cruise ship to tilt. (Other forms of transportation have their human
error problems as well) More on Fatigue and
other useful material.

Volume 4 Issue 5Investigators look at fuel system. (Something caused the loss of power)
World airline accidents in 2007. (Maintenance is in there as a contributor)
Qantas probe finds more faults. (What one
clogged drain and a cracked tray can do) Ageing electrics cause Safety problems.
(Most of today's aircraft are "fly by wire")
and much more.

Volume 4 Issue 4Pilot a hero at Heathrow. (I sure hope that it
stays that way) Pilots deceived by
fuel gauge. (Maintenance error set them up)
Baggage door open fatal. (Maintenance or
Pilot error?) Training lowers pilot error.
(Sure agree with that one. Works for maintenance also)
Medical Students learn how to prevent errors and much more.

Volume
4 Issue 2 Airline
fatal events 2007. (Better but
still too high) FAA boosts
wiring safety. (More
maintenance inspections is a great safety net)
Shortage of AMEs (Try paying
them what they're worth would help)
Controller error due to fatigue. (7 straight days and in double overtime
does that to you) Hard hats - A
good knight idea. (Long
overdue) Head injury numbers.
(These should make a believer
out of you) and much more.

Volume
4 Issue 1 Wrong
gas pumped in.
(Fortunately the system wasn't used or maintenance could have been
responsible for a lot of fatalities)
Engine blast peppers fuselage. String of blunders doom crew. (Often known as the Chain of Events)
Safety Culture can reduce Human Error. (Cliff Edwards sure has that right)
Hearing loss risk. Midnight shift nugget (Some good stuff here)
and much more

2008

Once more our thanks go out to Roger
Hughes & jetBlue for this excellent Safety information. May everyone have
a Safe 2008

Volume
3 Issue 46 Air
France crash report out. (Human error
once more) Flight
attendant blown out of aircraft. (Lucky it was still on the ground but
there's a design flaw here)
Safety Issues. (Training is a
Safety net that it doesn't pay to put holes in)
Africa - Highest number of accidents. (Africa, sadly, lacks a Safety culture)
and much moreMerry Christmas to all and a Safe
2008 Gordon & Roger

Volume
3 Issue 45 NTSB adds Worker
Fatigue to "Most Wanted" list. (It's time we recognize its dangerous
contribution to human error)
Air Transat rudder loss report is out.(Maintenance failed the tap
test) MD-90 loses 3 meter long
part on takeoff. (They called
it a mistake in the workshop)
A lot more on fatigue and more.

Volume
3 Issue 44 Faulty fuel
filter Fatal. (Maintenance
again) Guess the #1 air travel
threat? (It's not Ben
Laden) 70 years ago the
"Spruce Goose" flew. Graveyard shift linked to cancer (Another reason not to like it)
and much more on sleep or the lack of it.

Volume
3 Issue 42 Airbus ground accident. (Its not everyday that maintenance
gets to write off an aircraft with 0 hours on it)
Cockpit device averts collision.
(That's what it's designed to do)
AD coming for entertainment wires.
(The pilots will to be able
to turn off your TV) FAA
mandates new wiring safety measures.
(To protect the wiring from
maintenance) Fuselage
punctured. Breakfast is important.
(I like the part about
improved memory) and more.
Good stuff Roger. Thanks

Volume
3 Issue 41Pilot steps
into rotor blades. (A fatal
error)
Engine falls off airplane.
(That will get the passengers paying attention to the briefing)
Skimping on fuel. Forgot the battery.
(More like bureaucracy wouldn't buy them UNTIL this happens)
Fatigue - key to mistakes among pilots
(And maintenance also)
Missing wingtip OK to fly.
(Not if I'm in it)
Stressful jobs can be fatal and a lot more

Volume
3 Issue 40 Third
accident may be maintenance.
(We did it again) Pilot
slept on overnight flight (Not
the first time this has happened)
Safety Standdown draws hundreds (Excellent. Wish I could have been there)
Maintenance failed Sea
King. Direct Atlantic flights barred due poor maintenance. (Much better than aircraft ditches
in ocean due to poor maintenance)
Parts shortage grounds helicopters. Baggage falling from sky.
Oxygen and hydraulic oil kills(a must read if you didn't
know) and much much
more

Volume 3 Issue 39 27 Dash 8's grounded. (Likely more political than Safety) Hole in jet. (Human Error at work again) Aircraft Engineer crushed to death. (A Hit & Run???)
Hangar door death. (Short cuts
can have a nasty bite years later)
Pilot ignored 15 alarms. (Some
people just won't listen) More
Fatigue tips and a lot more Great job Roger & JetBlue. Thanks from
all of us.

Volume 3 Issue 37Operators cut corners at price of Safety.
(That's Risk Management at its worse)
Crane Operator not a marshaller.
(Assume did it again) Airbus lands with
parking brake on. (another job for
the computer to check) More on
Fatigue, a great poem and much more

Volume 3 Issue 36 Poor decision doomed jet. 95% air crashes
caused by human error. (We used to say 80%)Close calls - a forgotten message
(These are our "Free Lessons" we don't take advantage of)Fatal crashes down 65% (That's good
news) More on Fatigue and much more

Volume
3 Issue 34Last word
"Landing." The near miss (Also called the "Free Lesson")
Half of bolts below standard
( Not Good) and much more

Volume
3 Issue 33 Bombardier probes crash(es).
(Ouch; this is going to be costly) Hot Boeing windshields.
(Cross threading is so easy to avoid)
Human error caused A380 wing damage. (Airplanes don't attack hangars by
themselves; yet) Fatigue
fighters (We can always use
these but the price?) and much
more. Thanks Roger and
jetBlue for some interesting reading material we can use to learn from.

Volume
3 Issue 32Bolt missing in wing. (For want of a washer an aircraft was
lost) Passengers criticize
evacuation instructions. (Who
remembers the briefing?) Taiwan's
Unfriendly Skies. Fake engineers flew coop (10 years jail and a multi-million $ fine
is a strong motivator to leave)
Seatbelt kills Snowbird pilot. (Sadly,the problem was first detected 5
years earlier) and much more

Volume
3 Issue 31 China
Airlines maintenance under scrutiny. Qantas discovers a fake
maintainer signing out aircraft.(There has been fake pilots in
the past)Low fuel
error. (Lots of fuel, just in
wrong tank) Fuel truck
hits aircraft.(Fatigue strikes again) Safety Management Systems for maintainers
(This one is a must to read)
and more

Volume
3 Issue 30
Fuel gushes from aircraft. (Not Maintenance Error
I hope) NTSB maintenance
Safety Recommendations.
(The failure gave lots of hints before hand)
Both right engines fail.
(Finger trouble?) Managing
Stress. (Or it will manage
you) and much more

Volume
3 Issue 29Airline with worst baggage record fires workers for a different reason.
(Maybe they were trying to get
what they thought they were worth?)
Helicopter crew distracted. Deadly danger of distractions.
(A common part of modern life
that is so preventable)
Manslaughter charges too severe for maintenance lapse. (Is Revenge is the main reason for the
charges?) Qantas rues
crude repairs. (SOMEONE must
have thought it was the right thing to do)
and more

Volume
3 Issue 28 Airline employee dies. (Sounds all too familiar)
Maintenance leaves rag on generator. (Fortunately it only caused a small fire)
Maintenance error causes depressurization. (What ever happened to pressurizing
on the ground to test?)
Maggie's Law and FMS. (We need
this) and much more

Volume
3 Issue 27 Airline employee dies.
(Another
unnecessary death) Work before Safety
Inquiry (Each time you get away with it
makes it seem OK until one day...) Jury
awards $54 million for 2 injured in plane crash. (Ever wonder why aviation parts are so expensive?)
and more Thanks JetBlue for
helping keep us aware - it could happen to us!

Volume
3 Issue 26
Pilot Error strikes again,
(But fatigue, complacency and lack of awareness are the cause of the errors
in judgment) Helo
Accident could have been prevented (The loose B nut strikes again)
Woman killed by blade strike.
(Now that can be prevented) Accident caused by wrong glue (It was cheaper until the lawsuits start)
and much more

Volume
3 Issue 25 Runway not to blame. (But it will be a link in the chain of events)
Baggage loader locked in hold.(Lucky he had a cell phone)
World Airline Safety good
so far. (Unless you are one of
the 312 dead) Hospitals
using aviation Safety tools.
(I'm all for that) The
Human Factor (Done right it is a long term useful tool) Near collision.
(This is happening too often)
and more

Volume
3 Issue 24
Remembering Maggie. (fatigue
can and does kill) Loose
fuel fitting causes fire. (Not
the first and sadly likely not the last)
Faulty maintenance may lead to disaster. (I certainly agree) Maintenance sued. (maintenance sets the pilot up to make
his error) nose gear collapse
and more
And if you have a choice - fly JetBlue as they are taking Safety, your
Safety, seriously. Gordon

Volume
3 Issue 23 Oxygen
generators fuel fire.
(fortunately not onboard an aircraft this time) B 737 crashes; five killed,
(Africa once more adds to its sad score)Nose gear collapse,(That can happen when "gear
up" is selected and a maintenance error is involved) CRM saves lives
(Human Factors training for maintenance does also) and more

Volume
3 Issue 22 Engine failure traced to faulty FCU,( Human error once more)
Jury convicts ex aircraft
business owner,(Justification for this) Ten face prosecution over Sea King
tragedy,(Read how revenge is
used for what likely was likely a honest mistake) How much water should you drink? and
more

Volume 3 Issue 21 Forgotten cart leads to
aircraft damage. (Its easy to
forget when distracted) System to blame as well as pilot.
(Root causes often set the pilot up for his error) Faulty repair lead to
Chalks crash. (A bad repair
can take many years to kill) Deprivation hurts Safety and more

Volume
3 Issue 20
Loose fuel line causes power loss, (they just won't run without fuel -
another maintenance error) Hole
in fuselage, (another one but
not an Aloha thank goodness)
Insurance company sues pilot, Runaway trim may have caused fatalities,
(did maintenance play a role?) Crash
inquest hears Safety questions,
(management too focused on profit)
Fatigue vs. function and more

Volume
3 Issue 19Poor
maintenance, "sloppy" corporate culture blamed for fatal crash, (a reason to bring in SMS)
airline mechanic sucked in,
(not a good way to end your career)
cargo worker killed, (another
needless death) midnight shift
nugget (if it can help keep
you alert at that time - try it)
and more

Volume
3 Issue 18 Hole in fuselage ends NWA flight,
(happily not an "Aloha
convertible" hole) FAA
hands out Diamond Awards for "Excellence in Training," (good news for a change) Skyguide failures blamed for plane crash,
(charges of negligent
manslaughter will do nothing to prevent it from happening again)
could this be you? (read and
think about it. Would you be the person saying nothing?) and much more

Volume
3 Issue 13 Differing between human and mechanical failure,
(The odds are it was a human error)
elevator
partially detaches on takeoff,(How
many times had it been inspected between 1999 & 2005?)
fatigue's threats to air safety,(The greater the fatigue, the greater the "I don't care attitude") Pilots take
a nap while flying, and more

Volume
3 Issue 12 Death on the ramp,(Again) bump caps,
(Let he/she who has never bumped
his/her head speak up), US puts warning on Indonesian
airlines, Australia's safety record, Tips for fatigue,(Read this if you have a sleep problem or work shift work)and more

Volume
3 Issue 11
This one is late by my
error (05-07) Oil pump failure causes accident(maintenance forget to install
the bushings),
CRM Meltdown, Copter
crash blamed on maintenance,(Sadly, it happens again), Comair
says pilots errored
(so did we in the spelling)
and more

Volume
3 Issue 10 The importance of turnover
(The Mental Pictures must match), Indonesia's wild aviation,(Anything goes), The Near Miss (read this as this is what SMS is
all about), your heart at work, and more

Volume 3
Issue 9 New
discoveries in the Garuda crash, Pilots support Canadian Safety bill,(So do I),fatigue costing billions, longer breaks needed,
(More power to the "Power Nap") and more

Volume 3
Issue 7 Fatigue causes stab failure,
new scrutiny for tired aircraft metal. Long hospital shifts Increase fatigue
related mistakes, (that shouldn't be a
surprise), sleep
deprivation in the military, (now these
stats ARE a surprise), fatigue at
30,000 feet and more

Volume 3
Issue 6Aircraft propeller claims
life(not a pretty way to die but you won't
see it coming), workers injured when tire
explodes, airline will no longer punish for fatalities, lack of O2
almost destroys aircraft, night shift, (I sure agree with this article)crash report
reveals system flaws and more

Volume
3 Issue 2 NTSB updates, Cargo door opens in flight, (More lost baggage?)Russian air
Safety plan in the works (Excellent idea), drunken
Ukrainian pilots imprisoned in Norway, and more

Volume
3 Issue 1 2006 a good year for Safety,
(unless you were one of the 1292 killed) What
is ergonomics? (man vs.
machine) Ground damaged
aircraft lands Safely, (it
should never have taken off),Pilot with alcohol breath fired, Neglect and failures cause crash, (maintenance failed once more)
How to improve your memory and more

2007Thanks
Roger & jetBlue for a great year of Safety information. Happy 2007

Volume
2 Issue 41 US
Air Force has Safest year,(always
good to hear) paint chips
cause MD80 problems,(maintenance error?)
next
generation mechanic,(this guy has been around since the early
737 days and are calledunit jerkers) crossed
fuel lines, false indication causes fatalities,(sadly both maintenance & pilot error)managing arthritis (for those over 65 and some younger)
and more

Volume
2 Issue 39
Half of US runways lack a Safety zone, (Interesting to know how that compares to
the rest of the world)NTSB
accident reports - improper maintenance, contaminated fuel, improper
loading, plot ignored storm advice, pilot faulted in Nigerian crash,(human error at its worse)pilots can teach hospitals about patient
Safety(we all can
learn from the mistakes of others)and more

Volume
2 Issue 38Bad
week for Continental and not much better of Alaska,(Proves that pilots are human to)FAA-ATA Human Factors in Maintenance
and Ramp a success,(Its a
worthwhile subject) Transport
Canada to regulate maintenance hours of work, (Difficult but necessary) Avionics 70% of maintenance workload
in new fighter and more

Volume
2 Issue 37
Improper control cable routing, (independent inspections are supposed to
prevent this) 3 hurt in jet
blast, Nigerian plane crash blamed on weather and pilots, Tools make the
maintainer,(make him broke as
well) Concordes left to
rot, stressed out (This is
sad)- drink tea (this is a new one)
and more

Volume
2 Issue 36 What
comes after Human Factors? (excellent article on SMS) USAF
has decrease in fatalities, (Good
News) Engine failures point to
overhaul problems, Inflight fires are a Safety threat, (that's a given)
plane back row seats are no safer,(but planes don't back into mountains)
Long hours lead to medical errors and more

Volume
2 Issue 33 Human Error
in Brazilian collision, (no
maintenance error with a transponder I hope)
everyday error causes most airplane crashes, (but not everyday thank goodness)medical mistakes 30 times worse
than 9/11 (now if we could use
even a fraction of the homeland security money on this - think of the lives
we would save)fiery
statistics and more

Volume
2 Issue 26
Pilot error again in A 320 crash, aging rules don't apply to smaller
aircraft, near miss at O'Hare, pilot with alcohol on breath fired, geologist
killed by helicopter blade (this should not be happening), HF training contributes to a Safety break
(great)
and more

Volume
2 Issue 23 Lack of fuel
causes crash, maintenance errors result in $51 million settlement,
crew fatigue, human error leads to B 747crash, Jazz maintenance is the best
(Glad to hear that one)
and more

Volume 2
Issue 22 Workers legs are severed by B-747, Batteries caused fire? Maintenance issue
with tiny airline, eggs and you and more

Volume
2 Issue 20 A PIT of a landing, another fuel tank explosion, human error for
Cypriot Crash (maintenance set them up: contribute to their error)
shiftwork myths, (this is hard to believe)
beating tension headaches and more

Volume
2 Issue 19
This day (29 years) in history, another worker sucked into an engine,
(see Volume 2 Issue4)
jet runs off runway, FAA debuts online HF training, (and you can even take the course online)
bad repair causes crash, Human Error in the workplace and more

Volume
2 Issue 18 This day (10 years) in
history, B-1 damaged in gear up, Indonesia bans Boeing 737-200s, Plane
bumped by fuel truck, 10 tips for a better memory (I can sure use this one)
and more